Healthcare - Pioneer the Change

I wrote the following article for a business writing class I was taking but also to clarify things that are going on in the industry. I am an in the healthcare industry and I often feel it is confusing!

Pioneer the Change

Since
2010 a strong movement, with both an industry and governmental component, has
begun picking up momentum within the healthcare industry. This movement is taking the industry away
from the current model, fee-for-service, and bringing to the forefront a managed-care
model that is more focused on the quality of care that providers are offering
patients. Yet, the transition from one
model to another is a much larger undertaking than one might imagine. This transition requires the implementation
of new technology, the creation of federal and state policies to guide the use
of this technology, a different reimbursement model between providers and
insurance companies, and, the final component, physicians moving from
symptom-based- care to wellness-based-managed-care. The healthcare industry has recognized these
issues, but until recently there has been no way to make viable changes. My proposal to all healthcare stakeholders is
to use their multitude of services and standing within the healthcare industry
to be the instrument of change within the current system.

Yet
to understand the need for change, it is important to understand the current
model and the problems it presents. Fee-for-service
has filled the need for insured patient care, but physicians have had no
ability to oversee the complete picture of the patient’s health. As the system currently stands, a provider whether
a primary care physician or a specialist has very little access to the entirety
of a patient’s files and in turn the entire picture of their health and
wellness. This further plays out when individuals
become sick or injured while traveling; complete medical records, although
being stored digitally, are not being shared.
The fee-for-service model also leads to insurance reimbursement only
being allocated when an appointment or a procedure has taken place. There are no financial incentives for
physicians to have healthy patients. Providers
have been forced to see a large number of patients in order to receive an
average compensation and deals are often made between these same providers and
medical vendors, such as pharmaceutical companies, imaging providers, and
laboratories, to negotiate the best incentives for patients’ use of services. Although patients would often require these
services regardless of whether incentives were in place, these incentives
create a situation that could lead to extraneous bills being sent to insurance
companies, that in turn leads to insurance premiums rising, and at the same
time are beneficial to the physicians and their practices. We, as Americans, have already seen how this
model plays out: insurance premiums continue to rise, we have the first
generation that is predicted to have a shorter life expectancy than their
parents, and technology is advancing rapidly, but policies and laws are
delaying the full advantages it can offer.

Although
fee-for-service is the most common model today, Americans have already had a
taste of managed-care model in the form of the failed HMO offering of the 1980s
and 1990s.

Julie Barnes,
the director of health policy at the Bipartisan Policy Center, wrote the
following in an article she submitted to the Atlantic:

During
the years prior to WWII, fee-for-service originated as "traditional
indemnity" health insurance--you get a service, submit your claim, and
your insurer covers your incurred expenses. What we now think of as
"managed care" emerged around the same time, as prepaid insurance
plans. In a prepaid plan, beneficiaries pay a set premium in return for care
from a defined network of providers.

Due to wage controls during WWII,
employers began offering insurance benefits as a way to attract employees--a
trend which continues to this day. Indeed, a number of key trends in health
care emerged after WWII: medical and scientific technology advanced dramatically,
and more people enrolled in health insurance coverage. As health care costs
grew in subsequent years, managed care, which encourages greater control over
the utilization of health resources and services, also increased in the 1970s
and 1980s.

Unfortunately, managed care
ultimately failed to control health care costs, and increasing restrictions on
care led to a patient- and provider-driven political backlash in the late 1980s
and 1990s. (1)

The concept of
managed care in the 1980s and 1990s was destined to fail from its inception.
There was no viable method to care for a greater population or track the health
of patients from hospitals to the provider.
Without the ability to monitor the transition of care between
facilities, costs and the drain on resources were bound to increase
exponentially. There have been many
variations of the managed care movement from HMO’s in the 1980’s to today’s
Accountable Care Organizations and Patient Centered Medical Homes. Managed care options have maintained a high
probability to fail like the HMO’s of the 1980s, but now that the Supreme Court
has upheld the federal governments Affordable Care Act which was signed in
March of 2010, the healthcare industries model of business will ultimately be
forced to change.

In
March of 2010 the Affordable Care Act was signed and, when paired with the American
Recovery and Reinvestment Act, opened new opportunities for managed care (2).
The Affordable Care Act opened the opportunity for the creation of Accountable
Care Organizations and Patient Centered Medical Homes. To understand the significance of the
signings one needs to understand what they are. Accountable Care Organizations were
created on the belief that the goal of coordinated care is to ensure that patients, especially the
chronically ill, get the right care at the right time, while avoiding
unnecessary duplication of services and preventing medical errors (3). While a patient centered
medical home integrates patients as active participants in their own health and
well-being. Here patients are cared for by a physician who leads the medical
team that coordinates all aspects of preventive, acute, and chronic needs of
patients using the best available evidence and appropriate technology (4). Both of these organizations seem simple
enough, but without the ability to access data and the complete transition of
care from Hospital to Provider or Provider to Provider they are also destined
to fail.

Yet
the Supreme Court’s decision to uphold the Affordable Care Act in June of 2012
plays a major role in these areas of data access and transition. MTS Healthcare
summarized it well in writing:

While the goal
of the Affordable Care Act is to improve the quality of healthcare with a focus
on reducing cost the American Recovery and Reinvestment Act allocated billions
of dollars in incentives to providers and organizations that adopt Health Information
Technology such as Electronic Medical Records systems and Health Information
Exchanges. Both pieces of legislation share many of the same goals.

However, there
are distinct differences on how each law will accomplish these goals. Namely, the
Affordable Care Act focuses on changing the healthcare delivery system and
physician payment reform while American Recovery and Reinvestment Act focuses
on adopting Health Information Technology. (5)

The American
Recovery and Reinvestment Act, signed in February of 2009, created a range of
new possibilities for the healthcare industry.
It allowed the collecting of “big data” from laboratories, diagnostic
imaging companies, and pharmacies to begin.
This will provide the opportunity to see the volume providers are
billing, rank providers care against each other, and obtain a profile of
population health by tracking where bills are submitted. The American Recovery and Reinvestment Act’s
Meaningful Use Requirements are also now set to have two years’ worth of
collected “big data” which can help to change how care is managed.

In
spite of the laws and policies that have been put in place, bringing the
collection of big data to the fruition of practical use is something that has
yet to occur. In June of 2012, Dan
Riskin, the CEO of Health Fidelity wrote:

The
promise of big data in healthcare is revolutionary. Use of big data will ease
the transition to authentic data-driven healthcare, allowing healthcare
professionals to improve the standard of care based on millions of cases,
define needs for subpopulations, and identify and intervene for population
groups at risk for poor outcomes. To date, few healthcare professionals would
claim that the promise of big data has been fulfilled. (6)

To reiterate, Mr. Riskin believes, “to date, few healthcare professionals would claim that
the promise of big data has been fulfilled.”The collection and accessibility of big data
is essential. The industry knows this,
yet has been unsuccessful in achieving it at a national level, never mind a
global level. Efforts have certainly begun
with the utilization of Health Information Exchanges on city and state levels, but
the “holy grail” will be the ability to access a patient’s medical records residing
in California from a hospital in Spain. Although
these information exchanges are being developed at the lower tier of
healthcare, there are additional components that must come from government
agencies and national community registries.
These are only in their infancy and will need to be spearheaded by
vested, non-government agencies.

When
further exploring what needs to happen to bring data exchange to a global
medical team, there are three major obstacles being faced: the varied patient rights between states, how
to share information that is stored within an Electronic Medical Record to
various Information Exchanges, and how to collect information into one master
patient disease registry. Patient rights
are always difficult to handle due to both federal and state laws that are
already in place. The federal law is covered in the Health Information
Portability and Accountability Act of 1996, which establishes a general
protection of communicating with a patient and protecting their medical records
(7). The states add additional privacy laws protecting patient information; yet
this becomes a very interesting component when a resident of one state makes
use of a medical facility in another state, but the home state’s laws must be
observed. Concerns also extend into the
lack of standardization when different medical record software and exchanges
are brought into different states and even different facilities within the same
state; depending on the forms and policies in place patients are asked to opt
in, given the option to opt out, asked if pieces of information should be
excluded, etc. Due to this complexity, many health
information exchanges are hesitant to connect to different state exchanges.

The
second issue of sharing the information between health information exchanges is
a bit more complex. Databases are often set up using different fields to hold
the data. Establishing common community mappings will be critical in order to
share information effectively. Fortunately, some standards have been met and as
long as the systems can transfer the following industry standard data fields,
patient care can be managed. The fields that are needed to be transferred are: Allergies,
Conditions (Problems), Encounters, Healthcare Providers, Immunizations, Information
Source, Insurance Providers, Medications, Person Information (Demographics), Procedures,
Results, Support, and Vital Signs (8).

The American Recovery and
Reinvestment Act has begun to address some of the hurdles within the third
obstacle. Aside from stimulating the use of Electronic Medical Records, the Act
has established many guidelines for meeting and reporting Meaningful Use
Requirements. In order for providers to receive the monetary incentives from
implementing and using Electronic Medical Records, providers must currently
submit reporting measures on a yearly basis. Beginning in 2014, reporting will
be required to be submitted automatically by the providers’ electronic medical
record. This step will be critical to the success of any form of managed
care.

Collaboration
is critical to succeed in this government mandated, industry supported move
from fee-for-service-care to a national managed-care model. There have to be leaders
to connect all the pieces, to bring the parties to the table in order to be
successful in bringing managed-care to the nation. Insurers need to reach out
to the government, hospitals, providers, and patients to clear the final
obstacles. A push has to be made to create the common community data mappings,
to form common rules in transferring information between health exchanges, and,
most importantly, there needs to be common disease registries to research
ailments and determine which provider’s best care for any given disease. To this point no one has stepped forward to
pioneer the change, it is a daunting task, but the fact that the industry is being
forced to change provides healthcare stakeholders the opportunity to take the
lead and utilize their services to better enhance the lives of those they try
to help.